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Phone (international):

Do you participate in any social networking sites (e.g. Facebook, MySpace, LinkedIn)? If so, please list profile name(s) or web locations:

PRACTICING CHIROPRACTORS ONLY

(Please answer the following questions completely and truthfully. Your answers to the following questions will be kept confidential and is only for use within The Chiropractic Trust)

How many years have you been in practice?:

Are you in:
Solo Practice Partnership Group Practice?

What year did you graduate and from what school?

How do you define straight chiropractic and do you practice that way on a day-to-day basis?

Do you currently practice in a 100% non-therapeutic, straight model?
Yes No

If yes, how long have you practiced this way?

If no, are you either in transition or looking to transition to a non-therapeutic, straight model of practice?
Yes No

List the service(s) you currently provide in your office (e.g. X-ray, Thermography, sEMG, physical therapy, rehab, nutrition, pillow/braces, exercises, etc.):

What type of fee system do you currently offer (e.g. fee-for-service, Membership, GPC/BOTW)?

Are you a participant or provider (contracting/non-contracting) for any insurance company, including Medicare?
Yes No

If yes, list which ones:

Do you accept Personal Injury or Worker’s Comp cases or insurance?
Yes No

Do you submit insurance claims forms or provide superbills/receipts for the purpose of insurance reimbursement by your practice members?
Yes No

Do you currently belong to any state or national chiropractic associations?
Yes No

If yes, list which ones:

Do you currently hold a board or committee seat within any of the listed organizations?
Yes No

If yes, list which ones and which positions held:

If you are transitioning to the non-therapeutic model of practice, what is your estimated time goal for completion?

Please provide the names of two (2) members in good standing of the The Chiropractic Trust that would offer a recommendation for your membership application:

What school do you attend?

Are you interested in practicing the non-therapeutic, straight chiropractic model?
Yes No

Are you familiar with Membership-Style Practice?
Yes No

CHIROPRACTIC ASSISTANTS ONLY

How long have you worked as a Chiropractic Assistant?

What is the name and location of your Chiropractic employer?

Name:

Email:

Website:

Does your employer (chiropractor) currently offer chiropractic memberships to clients in your office?
Yes No

As a CA, what would you like to see available or offer as education or training from The Chiropractic Trust?

Terms of Acceptance & Commitment to The Chiropractic Trust

I, , have read, understand and agree that I have completed the above application correctly and truthfully, to the best of my knowledge.

I understand and agree that if accepted for membership, The Chiropractic Trust is primarily directed at preserving, protecting and promoting the rights and practices of the non-therapeutic, straight chiropractor without compromise and that my participation in this organization, or any of its functions, is completely and strictly voluntary and that I may withdraw as a member at any time for any reason.

I understand and agree to practice in accordance with the Constitution and By-Laws of The Chiropractic Trust to the best of my ability and I acknowledge that there are certain rights, benefits and privileges from participating in this organization and those same rights, benefits and privileges may only be received by my adherence to the same Constitution and By-Laws. I understand that should I no longer practice in a manner consistent with non-therapeutic, 171-C East Oxford St • Pontotoc, MS, 38863 662.489.3322 TheChiropracticTrust.com straight chiropractic or practice in direct violation of the Constitution and/or By-Laws of The Chiropractic Trust, as determined by the board, my membership will be subject to cancellation or may be placed in an alternative and more appropriate membership classification.

I understand and agree that as part of the rights, benefits and privileges afforded to me by The Chiropractic Trust, I may be privy to certain information that is proprietary in nature, copyrighted or otherwise protected, such as but not limited to policies, procedures, seminar materials, objectives, goals and professional positions and standards designed for or by The Chiropractic Trust and used to fulfill its missions and objectives. I agree to keep this information confidential when necessary by not sharing this information with other competing entities, chiropractic or otherwise, whether or not it is for financial gain.

I understand and agree to act and practice as a professional and conduct myself in a respectful, moral and ethical manner that is representative of the non-therapeutic, straight chiropractor and of The Chiropractic Trust.

Membership Payment Authorization Form
Please Choose A Membership Option and Complete Form Below

Membership Options:

Trustee Membership
Monthly ($35/month)

CA Membership
Yearly ($50/year)

Student
Free Until Graduation

Graduation Date: School:

(CHOOSE ONE)

By choosing one of the monthly recurring payment options above, I, (print name) , hereby authorize The Chiropractic Trust to bill the credit/debit card or checking account listed hereon for $ as indicated by my membership option above, on today’s date and each month hereafter and agree to perform the obligations set forth by the credit/debit card issuer and the terms of the membership agreement. I further authorize monthly payments to continue indefinitely or until I notify The Chiropractic Trust in writing to cancel the membership. (initial)

For CA Only

By choosing one of the annual payment options above, I, (print name) , hereby authorize The Chiropractic Trust to bill the checking account listed below for the amount indicated by my membership option above on today’s date and each year thereafter on the anniversary date of my membership join date and agree to the terms of the membership agreement. I further authorize annual payments to continue indefinitely or until I notify The Chiropractic Trust in writing to cancel the membership. (initial)

Card/Account # (last 4-digits only):
- - -

CVV (3-digits on back):
- -

I agree to notify the business in writing of any changes in my account information or termination of this authorization 30 days prior to the next due date of the charges. For ACH debits to my checking/savings account, I understand that because this is an electronic transaction, these funds may be withdrawn from my account each month as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute the company’s recurring billing with my bank or credit card company; so long as the transaction corresponds to the terms indicated in this agreement.

Checking/Savings Account (ACH)

Checking, Savings

Name on Acct:

Bank Name:

Account Number:

Bank Routing #:

Bank City/State:

Checking/Savings Account (ACH)

Card:

Cardholder Name:

Card Number:

Exp. Date:

CVV (3 digit number on back of card):

Download a Membership Application

PRACTICING CHIROPRACTORS ONLY

STUDENTS ONLY

CHIROPRACTIC ASSISTANTS ONLY

Terms of Acceptance & Commitment to The Chiropractic Trust

Membership Payment Authorization Form
Please Choose A Membership Option and Complete Form Below

Information below is encrypted, stored and protected offsite. This portion will be shredded after input.

Download a Membership Application

PRACTICING CHIROPRACTORS ONLY

STUDENTS ONLY

CHIROPRACTIC ASSISTANTS ONLY

Terms of Acceptance & Commitment to The Chiropractic Trust

Membership Payment Authorization Form Please Choose A Membership Option and Complete Form Below

Information below is encrypted, stored and protected offsite. This portion will be shredded after input.

Membership Payment Authorization Form
Please Choose A Membership Option and Complete Form Below